Workshop 9. Cytopathology of Solid and Cystic Neoplasms of the Pancreas: Everything You Need To Know For Daily Practice.

Transcription

1 Workshop 9 Cytopathology of Solid and Cystic Neoplasms of the Pancreas: Everything You Need To Know For Daily Practice Michelle Reid, MD Momin Siddiqui, MD,FIAC There are no disclosures necessary.

2 Cytopathology of Solid and Cystic Neoplasms of the Pancreas: Everything You Need To Know For Daily Practice Workshop # 9 Michelle Reid, MD, MS Momin Siddiqui, MD, FIAC Department of Pathology Emory University Hospital Atlanta, GA

3 No Disclosures In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation. This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA or approved for off-label uses of pharmaceuticals or devices.

4 NEEDLE ASPIRATION OF THE PANCREAS 1. Percutaneous fine needle aspiration biopsy (FNAB) Performed by a radiologist by either : A. Trans-abdominal ultrasound B. Computerized tomography (CT) guidance» Offers the best resolution of smaller lesions not visible by ultrasound 2. Endoscopic ultrasoundguided (EUS) FNAB Now the #1 technique for sampling solid pancreatic lesions and cysts Performed by a gastroenterologist An echoendoscope is inserted through the mouth into the duodenum Scope is placed against the stomach/duodenum to obtain a high-resolution image

5 INTRODUCTION Endoscopic ultrasound-guided (EUS) FNAB Advantages: Most cost effective and sensitive modality for investigating pancreatic masses Higher resolution for sub-centimeter (0.5 cm) lesions than CT» CT-guided FNAB detects lesions 1.0 cm Allows real-time visualization of needle during procedure Allows simultaneous diagnosis and staging

6 DIAGNOSIS OF PANCREATIC LESIONS Is challenging - SO WHY DO IT? Because cytologic diagnosis affects surgical management Pseudocysts, serous cystadenoma, pancreatitis REQUIRE NO SURGERY All other lesions/neoplasms REQUIRE SURGERY Initial assessment of pancreatic lesions is based on radiologic findings Most lesions are either cystic, solid or mixed

7 ABRIDGED CLASSIFICATION OF SOLID AND CYSTIC PANCREATIC NEOPLASMS Gross Configuration Neoplasms % Ductal Adenocarcinoma 85% Solid Neoplasms Pancreatic Neuroendocrine Tumor 3-4% Acinar Cell Carcinoma 1-2% (Solid-Pseudopapillary Neoplasm) 1-2% Pancreatoblastoma <1% Cystic -True cysts Serous Cystadenoma 1-2% Mucinous Cystic Neoplasm 1-2% Cystic - Intraductal Intraductal Papillary Mucinous Neoplasm 3-5% Cystic - Degenerative Solid-Pseudopapillary Neoplasm (Ductal Adenocarcinoma, Acinar Cell Carcinoma, Pancreatic Neuroendocrine Tumor) Entities in parentheses only rarely exhibit this gross configuration Modified from Klimstra et al. Archives of Pathology and Laboratory Medicine 2009; 133(3):

8 INTRODUCTION FNA diagnosis of pancreatic lesions requires correlation of: Cytologic findings Clinical findings Age, sex, presence/absence of jaundice, weight loss, Radiologic findings Tumor location (head, body or tail) Configuration (solid, cystic, mixed) Ancillary studies» Immunohistochemistry» Flow cytometry» Fluid analysis

9 INTRODUCTION Accuracy of FNAB On-site cytologic assessment IS A MUST Best performed by cytopathologist or cytotechnologist Reduces number of passes Reduces inadequate samples Saves time and money

10 Accuracy of Pancreatic FNAB Sensitivity for detecting malignancy: 86% - 98% for percutaneous FNAB 75% - 94% for EUS-FNAB Specificity for both approaches 100% False-negative results occur more frequently Well differentiated ductal carcinoma is misread as benign False-positive results also occur Reactive ductal cells (in chronic pancreatitis) are misread as malignant

11 SAMPLE PREPARATION AND EVALUATION 1. Prepare air-dried and alcohol-fixed slides A. Air-dried slides Stain with a Romanowski stain Diff-Quik Immediately evaluate adequacy Immediately triage specimens Flow cytometry (if lymphoma is suspected) Cyst fluid can be collected for analysis* B. Alcohol-fixed slides Papanicolaou and hematoxylin and eosin (H&E) 2. Collect needle rinses for: Cell blocks (place specimen in 95% alcohol or formalin) Immunohistochemical stains To distinguish ductal adenocarcinoma from its look-alikes To distinguish various other pancreatic neoplasms Flow cytometry (place specimen in RPMI) Culture and sensitivity Core biopsy optional

12 Pancreatic Cyst Fluid Analysis 1. Enzymes Pseudocyst or Non-Neoplastic Cyst Neoplastic Cyst amylase High low* lipase High low leukocyte esterase high low 2. Viscosity Non-Mucinous Cyst Mucinous Cyst viscosity < serum viscosity > serum 3. Tumor Markers Non-Mucinous Cyst Mucinous Cyst CEA Not elevated (<5ng/mL) Elevated (>200ng/mL) CA72-4 not elevated elevated CA19-9 not elevated elevated CA125 not elevated elevated CA15-3 not elevated elevated 4. Molecular Markers Negative for K-ras mutation Negative for LOH mutation Low quantity/quality DNA CEA, carcinoembryonic antigen; CA, cancer antigen; LOH, loss of heterozygosity. K-ras mutation LOH mutation or High quantity/quality DNA

13 Molecular Markers in Cyst Fluid Analysis RedPath Integrated Pathology has a commercially available molecular test for pancreatic cyst fluid and deparaffinized cell blocks Called PathFinderTG Includes 3 tests 1. k-ras gene point mutation 2. Loss of heterozygosity (LOH) analysis using 15 preselected genomic loci associated with tumor suppressor genes 3. Measure DNA quantity/quality in cyst fluid

14 The Molecular Test -PathFinderTG Each component test is defined as abnormal if: 1. k-ras gene point mutation» Proto-oncogene on chromosome 12p12» Considered high amplitude mutation if it involves > 75% of total DNA content» Suggests significant clonal expansion 2. LOH mutations in 2 of 15 genomic loci» Considered high amplitude mutation if it involves > 75% of total DNA content 3. A high quantity/quality of DNA content Based on these results there are 3 types of cysts

15 The Molecular Test -PathFinderTG Benign Non-Mucinous Cyst Benign Mucinous Cyst Malignant Cyst 0/3 abnormalities 1/3 abnormalities High amplitude K-ras or LOH mutation 1. k-ras gene point mutation 2. LOH mutations in 2 of 15 genomic loci 3. A high quantity/quality of DNA content

16 K-ras Gene Mutations Somewhat controversial in pancreatic pathology Some pancreatic carcinomas lack k-ras mutation Chronic pancreatitis may harbor k-ras mutation Pancreatic intraepithelial neoplasia (PanIN) may also harbor the mutation

17 Use of Immunohistochemical Stains in Diagnosis of Pancreatic Neoplasms Table from Archives of Pathology and Laboratory Medicine 2009; 133(3): [14]

18 Complications and Contraindications for Pancreatic FNAB Complications Minor Vaso-vagal reactions Pain Minor hemorrhage Major Acute pancreatitis (1% -3% of cases) Massive hemorrhage Perforation, sepsis Percutaneous pancreatic FNAB has been associated with needle tract seeding but EUS-FNAB has not Contraindications Bleeding disorder Unsafe needle access route For EUS-FNAB Gastrointestinal tract obstruction is an absolute contraindication Because of the risk of intestinal perforation

19 REPORTING TERMINOLOGY Diagnostic categories 1) Non-diagnostic 2) Negative for malignancy 3) Atypical cells present 4) Suspicious for malignancy 5) Positive for malignant cells 6) Neoplastic cells present

20 Diagnostic Categories 1. Non-diagnostic: Material is unsatisfactory: Because of low cellularity Because it does not represent the site biopsied 2. Negative for malignancy: Benign pancreatic epithelium

21 Diagnostic Categories 3. Atypical cells present: Atypia is mild Often in a background of pancreatitis A COMMENT is recommended 4. Suspicious for malignancy: Atypia moderate Worrisome for malignancy but: Qualitatively insufficient Quantitatively insufficient for a definite diagnosis of malignancy

22 Diagnostic Categories 5. Positive for malignant cells Cells shows obvious malignant features 6. Neoplastic cells present: When the cells are obviously neoplastic but not definitely benign or malignant e.g. Mucinous cysts

23 Contaminants in Pancreatic FNAB EUS-FNAB introduces gastrointestinal (GI) contaminants Not seen in percutaneous FNAB Distinction of GI tract contaminants from pancreatic ductal adenocarcinoma can be especially challenging GI tract contaminants include: 1.Duodenal epithelium 2. Gastric epithelium 3. GI tract mucin

24 CONTAMINANTS IN PANCREATIC FNAB Must know location of aspirated lesion to determine the most likely contaminant Lesions in pancreatic head and uncinate process duodenal epithelial contaminants Lesions in body/tail gastric epithelial contaminants

25 1. Duodenal Epithelial Contaminants Duodenum epithelium forms flat honeycomb sheets with goblet cells Tissue edges have distinct brush border best seen at very high power Distinction from well differentiated ductal carcinoma or a mucinous neoplasm can be difficult

26 Well Differentiated Ductal Adenocarcinoma vs Duodenal Contaminants Well differentiated ductal carcinoma - note pleomorphism, overlapping cells and absence of brush border Duodenal epithelium note bland uniform cells with 2-dimensional arrangement and brush border at edge of sheet

27 Duodenal Contaminants vs Mucinous Neoplasm Goblet cells Duodenal epithelium Mucinous neoplasm Duodenal epithelium has 2-dimensional honeycomb sheets with isolated goblet cells interspersed between benign columnar cells This helps to distinguish duodenal contaminants from a mucinous neoplasm which has a pure population of mucin-filled cells which are often crowded together and overlapping

28 2. Gastric Epithelial Contaminants Gastric epithelium on cell block Gastric epithelial mucin does not fill the entire cell but is confined to the superficial 1/3rd of the cell where it forms a distinct mucin-cup

29 2. Gastric Epithelial Contaminants It is even more challenging to distinguish gastric epithelium from mucinous neoplasms Note the distinct mucin cups in superficial 1/3 rd of cell (on the left)

30 3. GI Tract Mucin Thin watery GI tract mucin GI tract mucin may also be seen in EUS-FNAB Usually scant, thin and watery in quality Not abundant and thick like mucin in mucinous neoplasms Neoplastic mucin may have tumor cells admixed Thick colloid-like mucin in mucinous neoplasm

31 Normal Exocrine Pancreas - Acinar Cells Cells form acinar structures without distinct lumens Cells are pyramidal/triangular in shape with low N/C ratio, granular cytoplasm (zymogen granules), round nuclei, inconspicuous or prominent nucleoli Cells are bland in appearance

32 CYTOLOGY OF THE NORMAL EXOCRINE PANCREAS Ductal cells Form monolayer sheets Cells are evenly dispersed Well-defined cell borders Round nuclei with fine chromatin Nucleoli are absent or inconspicuous Ductal cells in honeycomb sheet

33 CYTOLOGY OF THE NORMAL PANCREAS Endocrine pancreas Islet cells Rarely sampled on a FNA Form loose aggregates or sheets with ill-defined cell borders Wispy amphophilic cytoplasm Round nuclei and fine chromatin Nucleoli are absent or inconspicuous Endocrine cells are small, monotonous with low N/C ratio and bland nuclei

34

35 CYSTIC PANCREATIC LESIONS

36 CYSTIC PANCREATIC LESIONS The majority are non-neoplastic or benign Pancreatic pseudocyst accounts for the majority (75%) Lymphoepithelial cysts Serous cystadenoma Mucinous cystic neoplasm Intraductal papillary mucinous neoplasm Solid neoplasms with cystic degeneration

37 ABRIDGED CLASSIFICATION OF SOLID AND CYSTIC PANCREATIC NEOPLASMS Gross Configuration Neoplasms % Ductal Adenocarcinoma 85% Solid Neoplasms Pancreatic Neuroendocrine Tumor 3-4% Acinar Cell Carcinoma 1-2% (Solid-Pseudopapillary Neoplasm) 1-2% Pancreatoblastoma <1% Cystic -True cysts Serous Cystadenoma 1-2% Mucinous Cystic Neoplasm 1-2% Cystic - Intraductal Intraductal Papillary Mucinous Neoplasm 3-5% Cystic - Degenerative Solid-Pseudopapillary Neoplasm (Ductal Adenocarcinoma, Acinar Cell Carcinoma, Pancreatic Neuroendocrine Tumor) Entities in parentheses only rarely exhibit this gross configuration Modified from Klimstra et al. Archives of Pathology and Laboratory Medicine 2009; 133(3):

38 CYSTIC PANCREATIC LESIONS Solid pseudopapillary neoplasm Serous cystadenoma Intraductal papillary mucinous neoplasm Mucinous Cystic Neoplasm Pseudocyst

39 The primary goal of FNAB of cystic lesions is to distinguish low-risk from high-risk pancreatic cysts

40 Low-risk pancreatic cysts Have a low risk of harboring malignancy Resected only if: Symptomatic When definitive diagnosis impossible High-risk pancreatic cysts Have a high risk of high-grade dysplasia or malignancy Depending on size and degree of dysplasia/carcinoma these may be resected Low-risk pancreatic cysts Pancreatic pseudocysts Serous cystadenomas Lymphoepithelial cysts High-risk pancreatic cysts Intraductal papillary mucinous neoplasm (IPMN) 30% harbor carcinoma Mucinous cystic neoplasm (MCN)

41 Case #1 68 year old male Presented with abdominal pain Abdominal CT scan revealed cyst in the tail of the pancreas EUS-guided pancreatic FNA was performed

42 Dx-Pancreatic Pseudocyst Turbid fluid was aspirated from the cyst Fluid was NOT mucinous or gelatinous Smears were hypocellular Cell block had granular background material with chronic inflammatory cells and pigment Yellow pigment = bile/hematoidin Brown pigment = hemosiderin Cell blocks

43 Pancreatic Pseudocyst - FNA Fluid collection of amylase-rich secretions, debris and blood Lacks a true epithelial lining Results in paucicellular smears with amorphous granular debris, macrophages, fat necrosis and pigment Pigment is important for diagnosis of pseudocyst Yellow bile or brown hematoidin pigment

44 Pancreatic Pseudocysts vs Mucinous Cystic Lesions Pancreatic Pseudocysts Fluid is turbid or necrotic Mucicarmine and Alcian blue (ph 2.5) Amylase CEA Negative High (>250ng/mL) Low (<5ng/mL) Mucinous Cystic Lesions Fluid is gelatinous Mucicarmine and Alcian blue (ph 2.5) Amylase CEA Positive Low ** High (> 200ng/mL)

45 Case #2 56 year old male Presented with abdominal pain Imaging studies revealed a complex 6cm solid and cystic mass in the pancreatic body Mass was resected

46 Dx: Serous Cystadenoma Clusters, sheets, single cells with clear cytoplasm, defined cell borders. PAS+ cytoplasm

47 LOW-RISK PANCREATIC CYSTS Solid pseudopapillary neoplasm Serous cystadenoma Intraductal papillary mucinous neoplasm Mucinous Cystic Neoplasm Pseudocyst

48 Case #2- Serous Cystadenoma Cystic spaces lined by bland cuboidal or low columnar clear epithelial cells

49 Serous Cystadenoma Extremely rare benign pancreatic cysts Most common in elderly females Radiology was once described as classical Multiloculated soap bubble cyst in the body of pancreas with central scar, calcification In recent studies CT was only predictive in 25% Excellent prognosis Complete resection offers cure Tumors in the head are more aggressive and are more likely to recur

50 Serous Cystadenoma - FNA Cyst fluid is usually thin and clear Unlike turbid fluid in pseudocyst or gelatinous fluid in mucinous cysts Aspirates are often hypocellular Often read as non-diagnostic Epithelium seen on smears in <20% of cases Radiologic findings are extremely CRITICAL to diagnosis Clear cells are AE1/AE3 +, EMA is focally + Amylase and CEA levels are low in cyst fluid Mucicarmine stain is negative Accuracy of preoperative diagnosis by imaging, cytology and chemical analysis is ONLY 20%**

51 Case # 3 56 year old male Incidental finding of 3cm peripancreatic cystic mass after abdominal CT scan EUS-FNAB was performed

52 Anucleated squames Mature lymphocytes Keratinous debris Cell block with gastric contaminants

53 Case # 3 Cytologic diagnosis Lymphoepithelial cyst No further treatment was given

54 LOW-RISK PANCREATIC CYSTS Lymphoepithelial cyst

55 Lymphoepithelial Cyst - FNA Occurs predominantly in males (80%), M:F 16:3 FNA similar to its histologic counterpart Fluid is thick, white and cheesy Cyst lined by mature squamous epithelium, contains keratin Surrounded by dense lymphoid infiltrate +/- germinal centers Smears have: Nucleated and anucleated squamous cells Keratin debris Mature lymphocytes, histiocytes, multinucleated giant cells Aspirates are usually DIAGNOSTIC Accurate FNA diagnosis obviates the need for radical surgery Cyst fluid has high CEA and amylase levels

56 HIGH-RISK PANCREATIC CYSTS MUCINOUS CYSTIC LESIONS Intraductal papillary mucinous neoplasm Mucinous Cystic Neoplasm

57 PANCREATIC MUCINOUS NEOPLASMS Mucinous cystic neoplasm (MCN) Primary mucin-producing cystic neoplasm Lined by bland mucin-filled columnar cells Has classical sub-epithelial ovarian-type stroma Stroma is ER+, PR +, may be luteinized Intraductal papillary mucinous neoplasm (IPMN) Primary mucin-producing cystic neoplasm Arises from the main or branch pancreatic ducts Lined by papillary mucinous epithelium with variable atypia

58 Mucinous Cystic Neoplasm Note tall mucin-rich columnar cells with underlying ovarian type stroma

59 Intraductal Papillary Mucinous Neoplasm Tall columnar mucin-filled cells with villi formation

60 Key Differences Between the Two Cysts MCN Large, circumscribed, solitary, calcified cystic lesions Not connected to the main pancreatic duct or branches Amylase levels are usually low >90% arise in the tail then body and head (10%) Patients are perimenopausal females yrs, F:M 20:1 MCNs have a sub-epithelial ovariantype fibrous stroma Malignant features include: Size >3cm Thick wall, calcifications Intramural mass/nodules IPMN Show diffuse ectasia of the main and/or branch pancreatic ducts Always arise in the main and/or branch pancreatic ducts Hence high amylase levels in cyst fluid >80% arise in the head of the pancreas Most patients are over 60 M = F or are slight > females No ovarian stroma seen in cyst wall Malignant features include: Size > 3cm Dilated main pancreatic duct Intramural mass/nodules

61 Cytologic Note abundant thick colloid-like mucin Similarities Both IPMN and MCN contain: Abundant thick mucin Difficult to express from the needle Difficult to spread on the slide Smear cellularity is variable Higher the grade of dysplasia, the higher the cellularity Cases associated with carcinoma are the most cellular Diff-Quik stain Pap stain

62 Similarities Between MCN and IPMN Both MCN and IPMN contain sheets and clusters of columnar cells with abundant intracytoplasmic mucin and variable atypia

63 Similarities between MCN and IPMN The mucin fills the entire cytoplasm and displaces the nucleus peripherally Note limited nuclear atypia

64 PANCREATIC MUCINOUS NEOPLASMS Nuclei are slightly pleomorphic with coarse chromatin and prominent nucleoli Mucin + Macrophages may be present

65 PANCREATIC MUCINOUS NEOPLASMS Papillary clusters may be seen in IPMN but are not typical in MCN Psammomatous calcifications may be seen in IPMN Architectural and nuclear atypia can be seen in both Includes hypercellularity Nuclear crowding Loss of polarity Hyperchromasia, pleomorphism High N/C ratio and nucleoli Single epithelial cells in mucin Papillary structure in an IPMN Note nuclear atypia with nuclear Crowding and hyperchromasia

66 PANCREATIC MUCINOUS NEOPLASMS Best correlate of invasion in pancreatic mucinous cyst is necrosis But this cannot to be used to definitively diagnose invasion on cytology Necrosis, inflammation and signet ring-like cells are more common in high-grade dysplasia or invasive cancer Single atypical cells within the mucin are also suggestive of carcinoma Note background mucin and necrosis Signet ring-like cells Single atypical cells

67 Case # 4 Consult case Female patient with a pancreatic tail cyst EUS-FNAB was performed

68 Diagnosis? Adenocarcinoma possibly arising in a neoplastic mucinous cyst

69 Key Point In Daily Practice Thick gelatinous mucin is DIAGNOSTIC of a neoplastic mucinous cyst even if diagnostic cells are not identified. - Correlation with imaging is required.

70 PANCREATIC MUCIN-PRODUCING CYSTS Definitive cytologic distinction between MCN and IPMN is not encouraged The best diagnosis for such lesions is: Neoplastic cells present. Neoplastic mucinous cyst Always comment on the presence and grade of dysplasia

71

72 SOLID PANCREATIC LESIONS

73 ABRIDGED CLASSIFICATION OF SOLID AND CYSTIC PANCREATIC NEOPLASMS Gross Configuration Neoplasms % Ductal Adenocarcinoma 85% Solid Neoplasms Pancreatic Neuroendocrine Tumor 3-4% Acinar Cell Carcinoma 1-2% (Solid-Pseudopapillary Neoplasm) 1-2% Pancreatoblastoma <1% Cystic -True cysts Serous Cystadenoma 1-2% Mucinous Cystic Neoplasm 1-2% Cystic - Intraductal Intraductal Papillary Mucinous Neoplasm 3-5% Cystic - Degenerative Solid-Pseudopapillary Neoplasm (Ductal Adenocarcinoma, Acinar Cell Carcinoma, Pancreatic Neuroendocrine Tumor) Entities in parentheses only rarely exhibit this gross configuration Modified from Klimstra et al. Archives of Pathology and Laboratory Medicine 2009; 133(3):

74 Ductal Adenocarcinoma 60% - 70% occur in the pancreatic head Range from well - poorly differentiated Diagnosis of poorly differentiated carcinoma is straightforward Well and moderately differentiated carcinoma may be difficult to distinguish from reactive ductal cells and GI tract contaminants

75 Poorly Differentiated Ductal Carcinoma

76 Poorly Differentiated Ductal Carcinoma Not a diagnostic challenge 3-dimensional groups 4-fold anisonucleosis is characteristic Irregular nuclei High N/C ratio Macronucleoli Abnormal mitoses Necrosis Single intact tumor cells are critical

77 Poorly Differentiated Ductal Adenocarcinoma 3-D crowded groups 4-fold anisonucleosis Disorganized sheets with hyperchromatic cells with irregular nuclei

78 Poorly Differentiated Ductal Adenocarcinoma MALIGNANT BENIGN

79 Poorly Differentiated Ductal Adenocarcinoma Cytoplasmic vacuoles are prominent in some cases

80 Well Differentiated Ductal Carcinoma Disorganized sheets similar to normal ductal cells Slight nuclear crowding Drunken honeycomb sheets Mild nuclear enlargement N/C ratio may remain low Anisonucleosis not as pronounced Normal pancreatic acini and endocrine cells are rare to absent

81 Case 5# - FNAB Pancreatic Mass Slightly drunken honeycomb sheet and focal suggestion of cellular dissociation (top right) Nuclei have irregular contours, with hypochromasia and prominent nucleoli

82 An extremely bland-appearing well differentiated adenocarcinoma with voluminous foamy cytoplasm Cells have abundant mucinous vacuoles and very bland almost benign cytologic appearance Closer examination revealed single intact malignant cells with nuclear irregularity

83 Diagnosis? Foamy Gland Variant of Well Differentiated Ductal Adenocarcinoma

84 Foamy Gland Ductal Adenocarcinoma

85 Foamy Gland Variant of Ductal Adenocarcinoma

86 Ductal Adenocarcinoma Immunohistochemical markers are not helpful in diagnosis: CK7, CK8, CK18, CK19 DUPAN-2 (pancreatic cancer-associated antigen) Mucin glycoproteins are variably expressed MUC1, 3, 4 and MUC5AC Molecular markers are helpful in diagnosis: K-ras mutation Loss of heterozygosity (LOH) mutation p53 mutation

87 Other Variants of Ductal Carcinoma

88 Squamous Cell Carcinoma of Pancreas Is an extremely rare variant of pancreatic carcinoma Incidence ranges from 0.5% - 5% Only diagnose this after metastases have been excluded and after a glandular component has been exclude (i.e adenosquamous carcinoma of pancreas) Has similar biologic behavior to ductal adenocarcinoma

89 Squamous Cell Carcinoma of Pancreas Malignant squamous cells are admixed with benign pancreatic ductal cells This was a case of primary pancreatic squamous cell carcinoma

90 Squamous Cell Carcinoma of Pancreas Most cases represent metastases From the lung, followed by cervix then esophagus Correlation with clinical information is paramount to accurate diagnosis

91 Case # 6 66 year old female Presented with abdominal and back pain CT revealed a 4 cm solid pancreatic tail mass EUS-FNA performed

92 Cytologic Dx: Undifferentiated Carcinoma with Osteoclast-Like Giant Cells All 3 cell types are represented Benign osteoclast-like giant cells Conventional ductal adenocarcinoma same case Cell block with benign giant cells

93 Osteoclastic- Giant Cell Carcinoma of Pancreas Extremely rare primary malignant pancreatic tumor Only 75 cases described in literature Mean age 62 yrs (range yrs) Mean size 5.7cm (range 2-17cm) Associated with ductal adenocarcinoma (40% of cases) May be focal or predominant Prognosis controversial: Some believe they are not as dismal as ductal carcinoma Others believe they are more aggressive Mean survival 12 months related to quantity of ductal carcinoma

94 Case # 6 Follow-up Distal pancreatectomy, splenectomy and partial gastrectomy were performed Diagnosis confirmed Patient received chemotherapy 7 months later CT showed peritoneal and lung masses Lost to follow-up

95 Mucinous Colloid Carcinoma of Pancreas

96 Mucinous Colloid Carcinoma of Accounts for <1% of pancreatic malignancies Commonly associated with IPMN Clusters and singly dispersed malignant cells in thick colloid-like mucin Signet ring cells are present Cytologic diagnosis is straightforward Pancreas

97 Mucinous Colloid Carcinoma of Pancreas Note clusters of slightly pleomorphic, hyperchromatic malignant cells in thick mucin

98 Chronic Pancreatitis Can present as solid pancreatic head lesion Distinction from carcinoma challenging on radiology Smears show fat necrosis, debris, fibrous tissue, reactive ductal cells Lymphohistiocytic infiltrates Fat necrosis Stromal fragments

99 Chronic Pancreatitis Atypical reactive ductal cells can be confused with ductal carcinoma Distinction between the 2 may require immunohistochemistry Reactive ductal cells

100 FNA: Atypical Cells Present Chronic Pancreatitis vs. Ductal Carcinoma Note the sheet-like arrangement, round nuclear contours and similarity between cells. This is marked reactive atypia

101 Benign ductal cells in honeycomb sheets Abnormal mitosis Well differentiated ductal carcinoma Drunken Honeycomb Sheet Reactive ductal cells in honeycomb sheets Well differentiated ductal carcinoma

102 Key Point In Daily Practice If atypical glandular cells are present and one cannot determine if they are neoplastic or reactive the best diagnosis is: Atypical cells present with COMMENT Correlate clinically and radiologically Repeat FNA may be warranted

103 Autoimmune Pancreatitis Lymphoplasmacytic sclerosing pancreatitis Can produce a mass effect in pancreas Patients may have rheumatoid arthritis, inflammatory bowel disease, primary sclerosing cholangitis serum IgG4 antibody Antinuclear antibody (ANA) + Anti-lactoferrin antibody + Rheumatoid factor +

104 Autoimmune Pancreatitis (AIP) Few reports on cytologic features Range from paucicellular to hypercellular aspirates Contain stromal fragments, lympho-plasmacytic infiltrate, eosinophils Minimal ductal epithelium IgG4 immunostain is positive in plasma cells

105 Case # 7 39 yo male was investigated because of family history of MEN1 syndrome Incidental finding of multiple 2-3cm pancreatic masses EUS-FNA was performed

106 DX: Well Differentiated Pancreatic Neuroendocrine Tumor Plasmacytoid cells Salt-n-pepper chromatin Pseudorosettes on cell block D Prominent nucleoli and acini

107 Case # 7 Immunohistochemistry: Synaptophysin, chromogranin positive Cytologic Diagnosis Well differentiated pancreatic neuroendocrine tumor MIB-1 quantification index by image cytometer was 3% (grade 2 PanNET)

108 Pancreatic Neuroendocrine Tumors Range cytologically from well - poorly differentiated Well differentiated pancreatic neuroendocrine tumor (PanNET) is the most common Poorly differentiated neuroendocrine carcinoma (PanNEC) is extremely rare Small cell carcinoma Large cell neuroendocrine carcinoma Prognosis is unpredictable

109 2010 World Health Organization Grading System for Pancreatic Neuroendocrine Neoplasms Tumor Grade Mitoses/10 HPFs MIB-1 Index (%) Grade 1 PanNET <2 2% Grade 2 PanNET % Grade 3 PanNEC >20 OR >20% HPF, high power field; PanNET, pancreatic neuroendocrine tumor; PanNEC, pancreatic neuroendocrine carcinoma.

110 Well Differentiated Pancreatic NET Well differentiated PanNET Hypercellular smears Uniform, dyscohesive cells Fragile, easily stripped cytoplasm Often have eccentric nuclei plasmacytoid appearance May resemble lymphocytes Classical salt-n-pepper chromatin on Pap/H&E stain Indistinct nucleoli usually May have prominent nucleoli Variable nuclear atypia Plasmacytoid cells PanNET with prominent nucleoli

111 Well Differentiated Pancreatic Endocrine Tumor Pseudorosettes are visible both on smear and on cell block

112 Well Differentiated Pancreatic Neuroendocrine Tumor - Pleomorphic Variant Single plasmacytoid cells and cells with focal degenerative endocrine atypia

113 Pancreatic Neuroendocrine Tumor Immunohistochemistry Positive for neuroendocrine markers Synaptophysin, chromogranin, CD56, CD57 Positive for keratin, CAM5.2

114 Pancreatic Neuroendocrine Carcinoma (NEC) Small cell carcinoma Extremely rare grade 3 neuroendocrine tumor of pancreas Includes small cell and large cell NEC Small cell carcinoma resembles same tumor in lung Nuclear molding, salt and pepper chromatin, crush artifact Large cell NEC Resembles poorly differentiated carcinoma Expresses neuroendocrine markers Always rule out metastasis before making this diagnosis

115 Case # 8 81 yo male Abdominal CT revealed 14cm heterogeneous pancreatic tail mass EUS-FNA performed

116 Hypercellular smears Acinar formation and naked nuclei Abundant granular cytoplasm Cells have basophilic cytoplasm, Nuclei with fine to coarse chromatin, inconspicuous nucleoli

117 Prominent nucleoli may be seen Cell block with acinar groups and trabeculae Trypsin positive Alpha-1-antitrypsin positive

118 Case # 8 Immunohistochemistry Trypsin positive Negative for synptophysin, chromogranin Cytologic diagnosis: Acinar cell carcinoma

119 Whipple resection performed Diagnosis: Acinar cell carcinoma, 15cm 2 years later patient is alive with liver metastases Case # 8 Follow-up

120 Acinar Cell Carcinoma Hypercellular smears Sheets and single acinar cells Cells are larger than normal acini Round to oval nuclei Nuclei have smooth contours, fine to coarse chromatin, single prominent (sometimes cherry red) nucleolus PAS+ cytoplasmic granules Cells are naked nuclei and background granular debris Normal pancreatic acini

121 Acinar Cell Carcinoma Tumor cells stain positively for: Pancytokeratin Pancreatic enzymes: Lipase, trypsin, chymotrypsin, α 1 anti-chymotrypsin, elastase and phospholipase A2 Do not confuse trypsin with -1- antitrypsin -1- antitrypsin is not a very carcinoma Because it also stains solidpseudopapillary neoplasm and pancreatic neuroendocrine tumors Trypsin

122 Solid-Pseudopapillary Neoplasm Tumor cells form vague clefts or spaces lined by bland epithelial cells with intervening myxoid stroma, thin-walled blood vessels and vesicular grooved nuclei

123 Case # 9 37 yo female Presented with a 4 cm pancreatic body/tail mass EUS-FNA was performed

124 Diagnosis: Solid-Pseudopapillary Neoplasm Complex branching papillae Monomorphic small cells with high N/C ratio, fine chromatin, nuclear grooves Papillary fronds with central myxoid stroma (on Diff Quik stain) and blood vessel (H&E)

125 Case # 9 Cytologic Diagnosis: Solid pseudopapillary neoplasm (SPN) Positive for β-catenin (nuclear) Focally weakly positive for pankeratin

126 Case # 9 Follow-up Tumor resected 1 month later Diagnosis of solid pseudopapillary neoplasm (SPN) was confirmed

127 Solid-Pseudopapillary Neoplasm Rare low- grade pancreatic malignancy Typically large, solid and cystic Usually arise in the pancreatic tail Seen almost exclusively in women (F:M 9:1) Third decade (mean age 28 years) or adolescence Cytologic features are distinctive Accurate FNAB diagnosis often made before resection

128 Solid-Pseudopapillary Neoplasm Fibrovascular core Nuclear grooves Vesicular nuclei with open, fine, powdery chromatin

129 Solid-Pseudopapillary Neoplasm Immunohistochemistry is characteristic and diagnostic Positive for vimentin: Frequently negative for cytokeratin Positive for: β-catenin (nuclear) CD56 (variable) CD10 Progesterone receptor -1- antitrypsin is not helpful because it is positive in SPN, acinar cell carcinoma and PNT

130 Pancreatic Neuroendocrine Tumor (PanNET) vs Solid Pseudopapillary Neoplasm (SPN) PanNET SPN Fibrovascular core (FVC) Salt-n-pepper chromatin Mucoid/myxoid FVC Fine chromatin, naked grooved nuclei

131 Solid-Pseudopapillary Neoplasm Tumor cells form vague clefts or spaces lined by bland epithelial cells with intervening myxoid stroma, thin-walled vessels and vesicular, grooved nuclei

132 Secondary Pancreatic Neoplasms Various tumors may metastasize to the pancreas Include: Lung (small cell and squamous cell carcinoma) Breast Kidney Lymphoma Less common tumors include: Ovary, colon and stomach History of previous malignancy and immunohistochemistry are helpful in diagnosis

133 SUMMARY - PANCREATIC FNAB Growing in popularity A cytopathologist /cytotechnologist at time of immediate evaluation improves adequacy and diagnostic yield Cytological evaluation of solid and cystic masses is complex Knowledge of types and location of the most common solid and cystic lesions is helpful in diagnosis Correlation with clinical and imaging data is paramount Be mindful that chronic pancreatitis and GI tract contaminants (in EUS-FNAB) may simulate carcinoma

134 SUMMARY - PANCREATIC FNAB Cytologic evaluation of pancreatic lesions is complex Correlation with clinical, imaging data is paramount Cytopathologist /cytotechnologist during immediate evaluation improves adequacy and diagnostic yield Be mindful that chronic pancreatitis and GI tract contaminants (in EUS-FNAB) may simulate carcinoma

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